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After describing the downside of working in long-term
care-long hours, relatively low pay, mountains of paperwork
and a terrible public image-Sherrie Dornberger, RN,
does not hesitate when asked why she has stayed in the
field for 26 years, 19 as a director of nursing at Pitman
Manor in New Jersey.
"There's this little guy who rolls down the hall
to my office," she said. "He has dementia;
he doesn't know my name. He'll sit in that doorway and
look at me like I've never been looked at before and
sing me a song that I can't even make out the words
to."
Dornberger knows that every morning, aides at Pitman
Manor take care to dress the man and put aftershave
on him. She knows that they make sure another resident
who wants hot oatmeal for her breakfast has it every
morning. She knows that her staff takes the residents
out to see the decorative lights during the holiday
season and puts on fashion shows for them.
"Even if it makes them happy for five minutes
of their day, that's the five minutes they'll remember,"
she said. "And that's what makes you feel good
about your work that day."
It's a feeling that Dornberger, president of the National
Association of Directors of Nursing Administration in
Long Term Care, would like to share with her fellow
nurses. "I would like more nurses to know,"
she said, "that it's really OK to be in long-term
care."
Long-term care has never been a particularly attractive
specialty to nurses fresh out of school and eager for
excitement. Hospitals have always paid better and offered
more fast-paced environments. Nurses with advanced degrees
have tended to enter into private practice or community
health.
In recent years, a host of other reasons-including
older and sicker residents, reports of high staff turnover,
stories of abuse and neglect and increasing litigation-have
contributed to a reluctance among nurses to enter traditional
long-term care settings. The number of license exams
administered to directors of nursing has fallen by about
40 percent since 1988, said Randy Lindner, executive
director of the National Association of Boards of Examiners
of Long Term Care Administrators.
Add that reluctance to an aging population and a nursing
shortage and you have an impending disaster, said David
Lipschitz, MD, Ph.D., professor of geriatrics and director
of the Donald W. Reynolds Center on Aging at the University
of Arkansas for Medical Science.
"I view long-term care as the No.1 health care
crisis facing the United States today," he said.
The solution to this crisis remains elusive, according
to those involved in long-term care. Some are fighting
for staffing ratios, others are trying to improve the
image of long-term care and market it to young people
as a career. Some say nothing will work until state
and federal governments provide enough money to pay
for care.
In the midst of this debate, a number of long-term
care facilities are pioneering new models of care for
the elderly, including homes in which people can grow
old and skilled nursing facilities that offer residents
more choices and participation in their own care.
These facilities and a growing number of services,
such as home health care, are spurred on by a generation
of consumers who are becoming increasingly selective
about where and how they want to grow old.
Then and now
About 20 years ago, long-term care meant a skilled
nursing facility in which nurses and aides cared for
elderly residents in varying stages of health or board-and-care
homes for people who could get around, but needed some
help with tasks such as bathing, walking and eating.
Today's long-term care also encompasses home care,
adult day care, adult foster care, community programs
for seniors, senior housing developments, assisted-living
facilities and subacute units for the very ill. Various
programs provide meals, cleaning services, health screenings
and transportation for people in their homes. Visiting
nurses and therapists provide extensive home health
services.
In assisted living facilities or residential care,
residents mostly live independently, with access to
help with cleaning, bathing, meals and medications.
Some long-term care providers have campuses that combine
independent-living services, such as senior housing
and home care, with a skilled nursing facility providing
a continuum of care for people as they grow older and
are less able to care for themselves.
"People want options to be able to stay as independent
as possible for as long as possible," said Marilyn
Rantz, Ph.D., RN, FAAN, professor of nursing at the
University of Missouri-Columbia and co-author of The
New Nursing Homes: A 20-Minute Way to Find Great Long-Term
Care.
As a result, by the time they reach a skilled nursing
facility, residents often are older and sicker than
they were 10 or 20 years ago. They have complicated
conditions from multiple chronic illnesses.
"People don't live in nursing homes like they
used to," said Margaret Nelson, MS, RN, director
of specialty services for the Evangelical Lutheran Good
Samaritan Society, which runs long-term care facilities
in 25 states. With 23,000 staff members and 27,000 residents,
Good Samaritan is the largest nonprofit provider of
long-term care in the United States, Nelson said. "We
used to see people come in at a lower level of acuity
and live with us," Nelson said. "Now, they
stay home longer because they have more choices."
Ten years ago, residents in their mid-60s came to live
at Pitman Manor, a United Methodist Home campus that
features senior apartments and a skilled nursing facility,
Dornberger said. "Now, they're moving in at ages
87 to 90."
Younger nursing home patients often have some form
of early dementia or Alzheimer's disease, said Jean
Bronson, RN, director of Country Care Convalescent Hospital
in Atascadero, Calif., and a past president of the National
Association Directors of Nursing Administration of California.
She described eight of the residents in her 60-bed facility
as "quite alert." The rest are in various
stages of dementia, she said.
Many skilled nursing facilities also serve as rehabilitation
centers for people coming from short-term hospital stays.
These patients, who once would have recovered in the
medical/surgical unit of a hospital, often require equipment
such as central IV lines and ventilators.
"Ten years ago, we wouldn't get anybody with an
IV. Now, it's just second nature to us," said Karen
McDonald, RN, senior vice president of clinical services
at Integrated Health Services Inc., a for-profit nursing
home chain with 260 homes and 16 hospitals around the
country.
Assisted-living centers, which are not required to
have an RN on 24-hour duty, also are experiencing greater
acuity rates, Dornberger said. "Long-term care
today is what acute care used to be and assisted living
is like what long-term care used to be," she said.
In some cases, residents stay in assisted-living facilities
longer than they should because they don't want to leave
and the staff doesn't want to make them leave, Bronson
said.
Although most directors of nursing say they would like
to have more registered nurses on staff-and a number
of studies have shown that residents in long-term care
facilities have better outcomes when RNs are involved
in their care-most long-term care facilities hire RNs
only as supervisors. They usually hire LVNs and certified
nursing assistants to take direct care of the residents.
Nationally, the annual turnover rate among CNAs is
76.1 percent, according to a report released last year
by the American Health Care Association, which represents
nonprofit and for-profit long-term care facilities and
services. In some places, it is more than 100 percent.
Most assistants make little more than minimum wage-the
national average is $8.60 an hour. As a result, RNs
and LVNs often find themselves supervising a poorly
paid, constantly changing staff.
A report released in February by the U.S. Department
of Health and Human Services found that more than 90
percent of nursing homes in 2000 did not have enough
aides to properly care for residents.
Increasing litigation and a list of regulations that
is second only to the nuclear power industry also make
nurses fear losing their licenses, even in homes that
provide top-quality care.
"It makes me dread September and October"
when surveyors do their inspections, Bronson said. "We
have a good reputation, but that could go in an instant."
First impressions
But Bronson believes that the industry's poor public
image is what keeps nurses away from nursing homes more
than anything else.
"In the old days, this was seen as a no-place
job," she said. "It wasn't considered abusive,
it was just boring. Now, it's considered abusive and
boring."
Many nursing homes do the best they can with the resources
they have, she said, but they are not the ones that
receive media attention. Janice Cameron, MS, RN, executive
director of the American Society for Long Term Care
Nurses and CEO of Geriatric Healthcare Consultants in
Broomall, Pa., agreed. "What you hear about are
a couple of bad apples and you write more regulations
for everybody," she said. "The majority of
nursing homes do a wonderful job."
Although the industry is trying to change its image,
with campaigns aimed at junior high and high school
students, it is having a difficult time attracting and
keeping nurses.
The national turnover rates for LVNs and RNs are 51.5
percent and 55 percent, respectively, according to the
health care association report. Many are moving into
home care or moving out of nursing altogether, Cameron
said.
McDonald said that although her facilities have a 1
percent vacancy rate for directors of nursing, about
60 percent of them stay at least two or three years.
The other 40 percent turn over constantly within two
years, she said.
Directors of nursing report that it has always been
difficult to attract nurses out of school to long-term
care. Nursing schools often do not present long-term
care as much of an option, they said. But the hospital
nursing shortage has made it even more difficult to
attract new nurses.
More than 20 percent of RN positions in nursing homes
were vacant last year, according to the health care
association. The need for RNs in nursing homes is expected
to increase by 44.2 percent between 2000 and 2020, according
to the report.
"When the hospitals get hit, we get hit worse,"
Cameron said.
Although nurses in long-term care generally do not
leave to work in hospitals, bonuses and higher salaries
are probably keeping some from leaving hospital jobs
for long-term care, nursing directors said.
Reformers, nursing organizations and organizations
for the elderly favor staffing ratios to ensure that
nursing home residents receive a minimum amount of care.
The Health and Human Services report recommends a minimum
of 1.3 hours of care per resident from RNs or LVNs and
2.8 hours from aides. Many nurses and reformers think
it should be higher.
The industry opposes ratios, saying that they don't
take into account varying acuity rates of residents
and that they could force homes to close if administrators
cannot hire enough nurses. Many facilities have already
decided that their acuity rates demand more skilled
nurses and are staffing above what the regulations require,
Cameron said.
Reimbursement debate
Nursing homes have continually lobbied for increases
in the payments they receive under Medicare and Medicaid.
These government-run insurance programs pay for three-quarters
of nursing home residents. Medicaid reimbursements vary
from state to state, but are about $100 a day for room,
board and nursing care, less than the price of many
hotel rooms, several directors of nursing said.
Home health care also has suffered because of declining
reimbursement from Medicare, said Carolyn Markey, RN,
president and CEO of the VNA of Boston. More than 3,000
agencies have closed because of that decline, she said.
But nursing home reform advocates contend that even
when nursing homes had generous reimbursement from Medicare,
many put it into profits instead of staff.
Any increase in reimbursement should be tied to hiring
more nurses and aides, they say.
Problems related to a lack of quality staff have existed
for at least 25 years, said Sarah Greene Burger, MPH,
RN, former executive director of the National Citizens'
Coalition for Nursing Home Reform and now a consultant
for the reform group.
She encourages the industry to look at homes that provide
quality care to elderly residents, despite the obstacles,
and figure out what they are doing right.
The new nursing home
Because people are staying home longer, many nursing
homes are not full, Rantz said. Homes in most states
are running at 70 percent occupancy. "It's nothing
like it was 10 years ago," she said, when occupancy
rates were around 99 percent.
Because of this, people looking for homes can "vote
with their feet," she said. If a place looks or
smells bad, she recommends turning around and leaving
immediately.
Some homes have welcomed new ideas, such as the Eden
Alternative, which encourages residents to bring in
pets and plants.
Martha and Mary Lutheran Services in Poulsbo, Wash.,
jointly operates a 190-bed skilled nursing home, 23
senior apartments and a child care center that serves
500 children.
As part of the program, staff members regularly take
a group of Alzheimer's patients to the infant care center,
where they can cradle and rock babies, said Denney Austin,
CEO of Martha and Mary Lutheran Services.
A growing number of homes offer resident-centered care,
which allows residents and their families to make their
own decisions about meals, activities, hours and general
care.
At Pitman Manor, patients and families meet regularly
with a team that includes a nurse, a dietitian and a
social worker to design a plan of care that encompasses
everything from the medications a resident needs to
what he or she likes to have for breakfast.
Some homes also have found ways to attract and retain
staff. Five years ago, Good Samaritan began a concentrated
effort focused on recruitment and retention. The company
has made salaries competitive, not only with other nursing
homes but also, in some cases, with area hospitals.
It offers options for education and continuing education,
including a distance-learning program with the University
of South Dakota, where the organization is based. It
also offers a CNA-to-RN program on-site, job sharing,
flexible scheduling and benefits packages.
"Our turnover rate has certainly gone down,"
Nelson said. The average stay for a director of nursing
at Good Samaritan is 14 years. "The more we lower
the turnover, the more people want to stay in our facility,"
she said.
Almost all of the nurses at Pitman Manor were formerly
aides, Dornberger said. Instead of recruiting from nursing
schools, United Methodist Homes decided to focus on
"growing its own" by offering employee scholarships.
As a result, Dornberger said, the new nurses are familiar
with residents, and they understand what it was like
to be a nursing assistant and can offer the respect
and support the assistants need.
A well-run long-term care facility offers a nurse many
things a hospital cannot, directors of nursing said.
Nurses are more independent. They can make changes more
easily than if they had to go through a hospital hierarchy.
They can get to know the residents and their families.
They can become part of those families.
Recently, Dornberger sent some of her staff to attend
a resident's 100th birthday party given by relatives.
The aides spent time carefully dressing the resident
for her party. They took pictures and made her an album.
Another time, one of Dornberger's aides arranged a
special anniversary dinner in the skilled nursing facility
for a man who lived in the senior apartments and his
wife, for whom the aide cared at the facility. "They
think of her as their daughter," Dornberger said.
"I believe there are a lot of nurses who have
a genuine love for senior citizens," Cameron said.
"It is really true nursing in the sense that you
get to know these people and you get to know their families.
Nurses will tell you, 'These residents don't live in
a nursing facility. I work in their homes.' "
Contact
Cathryn Domrose at kaguilar@well.com.
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